Sexuality research in India : An update

This review provides the available evidence on sexual dysfunctions in India. Most of the studies have concentrated on male sexual dysfunction and hardly a few have voiced the sexual problems in females. Erectile dysfunction (ED), premature ejaculation (PME) and combinations of ED and PME appear to be main dysfunctions reported in males. Dhat syndrome remains an important diagnosis reported in studies from North India. There is a paucity of literature on management issues with an emergent need to conduct systematic studies in this neglected area so that the concerns of these patients can be properly dealt with.


INTRODUCTION
Human sexuality is inherently related to some of the social and public health problems in India.These problems may involve contraceptive use, child abuse, sex education, legal issues of homosexuality and AIDS.These health problems have a significant impact on existing health infrastructure and budget.These problems also need to look within the context of poverty, stressful living situations, diverse cultural belief systems, quackery, ignorance and inadequate health services.However, there is little recognition of how these health problems are related to human sexuality and their dysfunctions.There is a need to understand how sexual attitudes, beliefs, and values act and influence these problems.Our cultural perspective can also shape the experience and understanding of these disorders. [1]There is a need to research sexual experiences and dysfunctions, which further influence adult behavior patterns in India.
In this review, our aim is to present sexual dysfunction from the Indian perspective.Available data, based clinical studies towards the problem of sexual dysfunction.The authors also concluded that PME is a state of hyper-sexual arousal.
Using the same cohort, Nakra and his colleagues (1978) [5] found that nearly 75% of the patients had practiced masturbation before developing potency disorders and nearly 43% had guilt associated with masturbation.The authors also found nocturnal emission and adolescent homosexual contacts in 95% and 16% of the subjects respectively and of these 69% and 39% respectively had associated guilt feelings.64% of the subjects considered loss of semen harmful to health.Kar and Verma (1978)  [6] studied the sexual lives of 72 married psychiatric patients and compared with 80 married relatives or friends from same socio-cultural background.With regard to marriage, 63% of subjects with schizophrenia and 24% of manic-depressives were married after the onset of the illness; 48.5% of the patients failed to perform sexually on suhag raat (first honeymoon night after marriage) compared with 18.7% of the controls faced same problem.Premature ejaculation was reported in 48% of subjects in 'patient group' and 40% in controls.Erectile impotence was reported in 27% and 13% in 'patient group' and 'control group' respectively.63.4% subjects from 'patient group' described their sexual relationship unpleasant as compared to only 2.5% from 'control group' considered unpleasant.
Kumar and his colleagues (1983) [6] conducted a study on 40 married male neurotics and 22 healthy controls from teaching hospital setting.They found that the sexual behavior of the neurotics was similar to healthy controls before the onset of illness.There was a significant decrease in the frequency of coitus, sexual satisfaction of self, perceived sexual satisfaction of the spouse and sexual adequacy.
Bagadia and his colleagues (1983) [7] used behavioral techniques to treat 26 married males with PME and secondary impotence; 58% patients improved with those techniques.Gupta and her colleagues (1989) [8] described the application of Modified Masters and Johnson technique in the treatment of sexual inadequacy in 21 married males.76.2% patients showed improvement after this technique.
Avasthi and his colleagues (1994) [9] conducted an outcome study of 66 male patients with psychosexual dysfunction in the context of socio-demographic and clinical variables.Short term outcome (of one year duration) and long term outcome (of seven years' duration) of those patients were recorded.Erectile dysfunction (ED), PME, and combination of ED and PME were reported by 30, 12 and 45% of subjects respectively.Dhat syndrome, with ED/PME, was reported by 9% of the subjects.Nearly 38% of the patients dropped out of the treatment ('dropout group').At one year follow-up, nearly 44% of the patients perceived improvement ('improved at one year group'), while rest did not ('no change at one year group').At the end of seven years, nearly 70% of the original 66 patients could be recontacted.Significantly, a greater number of subjects from the 'drop-out group' had active sexual dysfunction than other two groups.The study proved that improvement in the shortterm outcome indicated favorable long-term outcome.
Verma and his colleagues (1998) [10] analyzed data on 1000 consecutive patients with sexual disorders attending the psychosexual clinic at the tertiary care setting.They found premature ejaculation (77.6%) and nocturnal emission (71.3%) frequent problems followed by a feeling of guilt about masturbation (33.4%), small size of the penis (30%) and erectile dysfunction (23.6%).Excessive worry about nocturnal emission, abnormal sensations in the genitals, and venereophobia was reported in 19.5%, 13.6% and 13% of patients, respectively.
A file review of 178 male patients with sexual dysfunction by Avasthi and his colleagues (2003) [11] revealed that high income, married status, presence of partner at evaluation, and liberal attitude towards sexuality increased the chances of selection of behavioral sex therapy.The outcome of therapy was associated with treatment adherence.Participation of the spouse resulted in lower dropout rates.
Kendurkar and his colleagues (2008) [13] assessed the pattern of sexual dysfunction in the patients attending a marriage and sex clinic from 1979 to 2005 by looking into their medical records.After reviewing the data of 1242 patients, they found premature ejaculation being the most common complaint and the most commonly diagnosed clinical entity, followed by male erectile problems and Dhat syndrome.

Sexual dysfunction in females
As compared to male sexual dysfunction, a few Indian studies are available in the area of female sexual dysfunction.This area remains largely unexplored.Agarwal (1977) [14] reported a study of 17 female cases of frigidity.All except one presented with neurotic or somatic symptoms.Frigidity was associated with ignorance regarding sexual activity, fear of pregnancy, marital disharmony, lack of emotional atmosphere, tiredness and poor precoital attention.Superficial psychotherapy and guidance helped 65% of the subjects with frigidity.
In the review by Kulhara and Avasthi (1995), [15] there was mention of one unpublished study from Chandigarh which documented 13 female patients out of 464 attenders of a special clinic dealing with marital and sexual dysfunctions.Vaginismus, dyspareunia and lack of sexual desire were the main problems reported.
Kar and Koola (2007) [16] conducted a postal survey among English-speaking persons from a south Indian town and [Downloaded free from http://www.indianjpsychiatry.org on Thursday, November 29, 2012, IP: 182.68.49.12] || Click here to download free Android application for th journal found orgasmic difficulties in 28.6% females.Moreover, almost 40% of females reported to have never masturbated.
In the study among 100 consecutive women attending the Department of Pediatrics for the care of non-critical children in a tertiary care teaching hospital, Avasthi and his colleagues (2008), [17] found 17% of the subjects encountered one or more difficulties during sexual activities.These difficulties were in the form of headache after sexual activity (10%), difficulty reaching orgasm (9%), painful intercourse (7%), lack of vaginal lubrication (5%), vaginal tightness (5%), bleeding after intercourse (3%) and vaginal infection (2%).14% subjects attributed these difficulties to their own health problems; further lack of privacy (8%), spouse's health problems (4%) and conflict with spouse (4%) were the other cited reasons for those difficulties.None considered their sexual difficulty significant enough to demand a thorough clinical assessment.
In another cross-sectional survey of 149 married women in a medical outpatient clinic of a tertiary care hospital, Singh and his colleagues (2009), [18] reported female sexual dysfunction (FSD) in 73.2% subjects of the sample.The complaints elicited were difficulties with desire in 77.2%, arousal in 91.3%, lubrication in 96.6%, orgasm in satisfaction in 81.2%, and pain in 64.4% of the subjects.Age above 40 years and fewer years of education were identified as contributory factors.Women attributed FSD to physical illness in participant or partner, relationship problems, and cultural taboos but none had sought professional help.
Behere and Natraj (1984) [21] and Bhatia and Malik (1991) [23] found that the patients with symptoms of Dhat syndrome were mostly young, recently married, poor, rural and from family with conservative attitudes towards sex.Most studies found that these patients lose their semen in sleep, with urine, masturbation, hetero/homosexual sex.
Behere and Natraj (1984) [21] and Bhatia and Malik (1991) [23] explored the patients' beliefs regarding composition of Dhat; found majority believe semen, followed by pus, sugar, concentrated urine, infection or "not sure."Majority considered masturbation and/or excessive indulgence in sexual activities as important causative factor, followed by venereal diseases, urinary tract infections, overeating, constipation or worm infestation, disturbed sleep or genetic factors.
Regarding management of Dhat syndrome, Wig (1960) [26] suggested emphatic listening, reassurance and correction of erroneous beliefs.Avasthi and Gupta (1997), [27] in their manual proposed that the management of Dhat syndrome involves sex education, relaxation therapy and medications.
Prakash and Meena (2007), [28] provided an explanation regarding this belief derived from the anatomy and physiology of penis.They proposed that patients with Dhat syndrome believe that whatever blood is collected in cavernous spaces during erection, probably converts into semen.Hence, with every sexual activity they lose blood; as blood is their source of energy, they lose energy everyday becoming more weak and lethargic.

CONCLUSION
This review highlights the available evidence in the field of psychosexual medicine in India.It is important to mention that all studies were from a hospital setting and none from community.Only a few studies explored female sexual dysfunction.Very few studies spoke about management issues.Dhat syndrome could be an important diagnostic entity to be researched.There is a strong need to perform studies in these areas.